Preoperative assessment before obstetric surgery may be required during the third trimester, usually in the high-risk parturient at an anaesthetic antenatal clinic, in the hours preceding surgery in the elective or semi-elective case, or shortly before an emergency procedure in the non-prepared anxious mother. It may also occur before early obstetric procedures such as cervical cerclage. Preoperative assessment in non-obstetric surgery is discussed in Chapter 8, Incidental surgery in the pregnant patient.
Problems and special considerations
Women may be anxious about anaesthesia and surgery when pregnant, particularly in the non-planned setting.
Women may wish their partners to be involved in all stages of delivery, and their presence during the preoperative assessment allows them also to be informed of ensuing events.
When the anaesthetist and patient do not speak the same language fluently, a medical translating service should be involved rather than relying on family translation.
Management options
In the elective or semi-elective setting, time can be given to a relaxed preoperative assessment. In addition to questions asked in a routine non-obstetric preoperative assessment, medical issues related to this and previous pregnancies or deliveries (in particular, neuraxial or general anaesthesia) should be discussed. The airway should be carefully assessed, given the increased incidence of a difficult airway in the obstetric population (see Chapter 38, Failed and difficult intubation). Once information has been gathered, a clear description of planned events, proposed management and risks should take place (see Chapter 169, Consent); postoperative analgesia should be discussed. If pre-assessment has occurred in the antenatal clinic, there may be time to seek further information if necessary. National Institute for Health and Care Excellence (NICE) guidelines recommend that a preoperative haemoglobin should be checked but that a group and save is unnecessary before routine elective caesarean delivery; local policy should be followed. Locally written information about obstetric anaesthesia should be given if available; alternatively, women can be directed to reputable internet sources such as labourpains.com. An opportunity to ask questions and address concerns must be given.
In the urgent setting, focused, closed questions can be useful to gather salient information. Some information should have been imparted by the attending midwife, such as gestation, parity, labour progress and indication for surgery. A focused assessment in the urgent setting may include:
• Have you had any problems in this pregnancy such as high blood pressure or diabetes?
• Do you have any medical problems unrelated to pregnancy, for example asthma or heart problems?
• Do you take any regular medications? Are you allergic to any medications?
• Have you had any problems with any kind of anaesthetic before?
• Has your epidural been working well for you?
• When did you last eat anything?
The airway should always be assessed, regardless of the urgency of the situation, and results from a recent full blood count and group and save status should be seen. Haemodynamic status must be noted. The anaesthetist should then describe planned anaesthetic technique and in what circumstances this might be deviated from, and any additional steps that might occur, for example plane blocks for analgesia after general anaesthetic.
Local protocol should be followed regarding preoperative drug administration; ranitidine and metoclopramide can often be administered before surgery. The preoperative visit must be carefully documented in the patient’s notes.
Most hospitals also run an anaesthetic clinic at which parturients with particular risk factors are seen. Referral criteria are hospital-specific; common reasons include obesity, underlying medical conditions, back surgery, previous anaesthetic problems or known obstetric issues such as abnormal placentation or triplet delivery. Patients are usually seen in the early third trimester (or earlier, depending on severity of condition), which allows time to seek further information if necessary, for example details of previous anaesthesia or back surgery, or to arrange further investigations as indicated. Any encounter with the parturient may be seen as an opportunity to provide anaesthetic antenatal education.
Key points
• The preoperative assessment must be seen as a key interaction for information gathering and provision, and for developing trust between the anaesthetist and the patient.